Provider Demographics
NPI:1063711869
Name:WIESE, JOANNA ELISE
Entity type:Individual
Prefix:MS
First Name:JOANNA
Middle Name:ELISE
Last Name:WIESE
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:JOANNA
Other - Middle Name:ELISE
Other - Last Name:TEMPLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:9169 W STATE ST STE 725
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83714-1733
Mailing Address - Country:US
Mailing Address - Phone:208-828-7581
Mailing Address - Fax:
Practice Address - Street 1:90 HOPE DR BLDG 6000
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME AFB
Practice Address - State:ID
Practice Address - Zip Code:83648-1062
Practice Address - Country:US
Practice Address - Phone:208-828-7581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-18
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID203430103TC0700X
KS2526103T00000X
MO2017016784103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical